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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602964
Report Date: 08/15/2023
Date Signed: 08/15/2023 11:40:57 AM

Document Has Been Signed on 08/15/2023 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PACIFIC HORIZONFACILITY NUMBER:
198602964
ADMINISTRATOR:KIM, MICHAELFACILITY TYPE:
735
ADDRESS:9115 UNION STTELEPHONE:
(562) 368-1479
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 6CENSUS: 4DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff Juana BeckerTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Juana Becker and explained the reason for the visit. Shortly thereafter Administrator Mylene Bumanlag arrived. The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Staff Juana Vecker today 08/15/2023 at 9:20 AM and the following was observed
Facility contains 4 Client Bedrooms and 2 client bathrooms dining room, kitchen, and TV room.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster preparedness, and Emergency Intervention.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed and was given per physician's directions.
4 Client Files and 6 Staff Files were reviewed.
Interviews were conducted with 1 Staff and 1 client. 3 client's were at day program.
Hot water temperature measured 140 F. and was not between 105 F. and 120 F. and did not meet Title 22 Regulations.

Deficiency cited on 809 D. Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2023 11:40 AM - It Cannot Be Edited


Created By: Glenn Trueman On 08/15/2023 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC HORIZON
FACILITY NUMBER: 198602964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with Hot water temperature in 2 client restrooms having measured 140 F.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Facility to adjust remperature by POC due date.
Administrator adjusted to 115 F.
Deficiency cleared at visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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